Terminology in Health Care and Public Health Settings Unit 17 Definitions and concepts in the EHR.

Terminology in Health Care and Public Health

Settings Unit 17

Definitions and concepts in the EHR

Component 3/Unit 17aHealth IT Workforce Curriculum

Version 1.0/Fall 20102

In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison…if wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present.

Florence Nightingale 1863

Interoperable Systems

• Exchange data seamlessly between systems

• Must have data coded in a standard format that matches data structures in other systems to accomplish data exchange

• Use standardized terminologies



Terminology

• Special technical language used in a particular field of interest also called language for special purposes (LSP)

• Set of terms representing the system of concepts of a particular subject field (ISO)



Standardized Terminologies

• Allow the tracking of adverse events

• Documentation of services for reimbursement

• Advance the science of care delivery

• Allow the comparison of data captured in different systems for outcome management

• Facilitates the linkage of diagnosis-interventions-outcomes



Classifications

• Taxonomic structures most commonly used in health care are classification systems

• Non-combinatorial hierarchical languages designed to categorize objects

• Objects classified are generally patient diagnosis and care interventions and implemented as interface terminologies at the point of care (i.e. ICD-9)



Common Medical Terminologies

• Current Procedural Terminology (CPT)• Diagnosis Related Group (DRG)• International Classification of Diseases (ICD)• International Classification

of Diseases-10-Clinical

Modification (ICD-10-CM)



Common Nursing Terminologies

• North American Nursing Diagnosis Assoc ion (NANDA)

• Clinical Care Classification (CCC)

• Nursing Intervention Classification (NIC)

• Perioperative Nursing Data Set (PNDS)

• International Classification for Nursing Practice (ICNP®)



National Committee on Vital and Health Statistics

• Recommends adoption of Health Level-7 for messaging, clinical encounters

• Recommends adoption of SNOMED CT for Diagnosis and problem list, Non-laboratory procedures and interventions, Anatomy and Nursing data



SNOMED CT

• Systemized Nomenclature Medicine-Clinical Terms

• An agreement has been signed between the US Government and College of American Pathologists allowing free distribution of SNOMED CT in the US



Health Level 7

• Level Seven refers to the highest level of the International Organization for Standardization (ISO)terminology model for exchange of information between information systems

• Addresses definition of the data to be exchanged, the timing of the interchange, and the communication of certain errors to the application



Logical Observation Identifier Name Codes

• Originally developed to provide a standard set of codes and names for the electronic reporting of laboratory results

• LOINC has expanded to include items related to the measurement of clinical observations, such as blood pressure and symptoms



Summary

• To achieve data exchange between interoperable systems requires that data be formatted in a standard manner

• Standardized healthcare terminologies allow for the design of interoperable information systems

• Standardized healthcare terminologies describe patient diagnoses, interventions, and outcomes



Terminology in Health Care and Public Health Settings Unit 17 Definitions and concepts in the EHR.

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